GRADUATE MEDICAL EDUCATION VISITING RESIDENT APPLICATION …€¦ · 17.04.2018 ·...

GRADUATE MEDICAL EDUCATION VISITING RESIDENT APPLICATION FORM

COMPLETED BY THE RESIDENT Name:______________________________________________________ Email:___________________ (Last Name) (First Name) (MI) Social Security # ____________________DOB:_____________ Sex:____ NPI:_____________________ Name of Current Sponsoring Institution:____________________________________________________ Name of Current Residency Training Program:_________________________________ PGY:__________ Preliminary Year (Y/N)_______ If Yes, what training program will you be entering:__________________ Department / Program Requested:_________________________________________________________ Name of Rotation: _______________________ Date From:_______________ Date To:______________ Medical School: _________________________________________________ Grad Date:_____________

ECFMG Date (if applicable): _______________

I agree to provide all other information and supporting documentation as requested at http://gme.uchc.edu/ ______________________________________ _______________________________________ (Print Name) (Signature)

COMPLETED BY THE VISITING RESIDENT

Name:________________________________________ DOB:______________ SSN # _______________ (First Name) (MI) (Last Name) (Degree)

Contact Phone #:______________ Email: _______________________ Sex: ____ NPI: ______________ _ Medical School: _________________________________________________ Grad Date: _____________ ECFMG Date (if applicable): __________________ Visa Status (if applicable): ______________________ Name of Sponsoring Institution: __________________________________________________________ Name of Current Residency Training Program: _________________________________ PGY:__________ Name of Current Residency Training Program Director:_________________________________________ Are you currently doing a Prelim Year? (Y/N)_______ If Yes, what training program are you planning on entering?____________________________________

UConn Department / Program Requested: ___________________________________________________

Name of Rotation: _______________________ Start Date:______________ End Date_______________ Will you have travelled to a country identified by the C.D.C. (http://wwwnc.cdc.gov/travel/notices) as “warning level 2” or above within four weeks from the requested rotation start date? ______________ If yes, please attach a separate explanation.

I agree to provid e all oth er inform ation and supporting documentation as requested at: h ttp://gme.uchc.edu/visitingresidents

______________________________________ _______________________________________ (Print Name) (Signature)

COMPLETED BY UCONN SPONSORED PROGRAM DIRECTOR (to be forwarded to the UCONN GME Office)

I approve this request and attest this visiting resident rotation will not create any issues with availability of faculty supervision, adequacy of case volumes, learner interference, or any other items that will negatively impact the educational experience of the currently scheduled learners.

______________________________________ _______________________________________ (Print Name) (Signature)

An Equal Opportunity Employer

http://gme.uchc.edu/http://wwwnc.cdc.gov/travel/noticeshttp://gme.uchc.edu/visiting

Connecticut Children’s Medical CenterOffice of Medical Education

282 Washington Street Hartford, CT 06106

UNIVERSITY OF CONNECTICUT and OTHER AFFILIATED PROGRAMS

RESIDENT/FELLOW REGISTRATION and ASSIGNMENT AUTHORIZATION FORM

PERSONAL DATA

Name: Credentials (MD, DO, DMD, etc): ___ Pager#:

Street Address: Preferred Cell #:

City: State: Zipcode: Preferred Email:

Last 4 digits of SS#: DOB: Do you have a Federal DEA #: Yes No If yes, type your Federal DEA #:

Do you have a visa? Have you had EPIC Training? Yes No What is your NPI #:

If yes, where did you have EPIC Training? What type of EPIC Training?

CURRENT RESIDENCY/FELLOWSHIP TRAINING

Residency/Fellowship Program:

Program Start date:

Program Grad Date:

School/Hospital: Uconn Resident or Uconn Fellow

Current PGY Level: Non-Uconn Resident or Non-Uconn Fellow Program Director: Telephone:

Email:

Program Coordinator: Telephone:

Email: IDENTIFICATION OF ASSIGNMENT AT CT CHILDREN'S MEDICAL CENTER

Assignment/Site Supervisor: From: To:

Assignment/Site Supervisor: From: To:

Will you be oncall during the academic year? Yes: No: ASSIGNMENT APPROVAL

Resident/Fellow’s Signature Program Director’s Signature Date

If completing this form electronically, typing your name in the signature space provided above will be considered a legally

binding signature indicating your approval of and agreement to the terms/conditions contained in this document.

To be filled out by the CT Children’s Medical Education Central Registration Office

(Resident’s or Fellow’s Name) has completed all necessary orientation materials, and may obtain a CCMC Photo ID badge and start the rotation.

Medical Education Department Central Registrar’s Signature Date

Email Registration form to Lisa Malecot, [email protected]

Revised:4/17/2018

mailto:[email protected]

UNIVERSITY OF CONNECTICUT SCHOOL OF MEDICINE VISITING RESIDENTS/ FELLOWS LETTER OF UNDERSTANDING

This Letter of Understanding (“Letter”) confirms that __________________________________________ (Sponsoring Institution)

will permit____________________________________________________ to participate in a rotation in (resident/fellow name)

the ______________________________________program at the University of Connecticut School of (UConn Program)

Medicine (“UConn SOM”). The above sponsoring institution and the UConn SOM acknowledge that this is contingent upon an offer of an educational appointment by UConn SOM and acceptance by the resident/fellow. Condition of the rotation upon offer and acceptance are as follows:

1. Term of Rotation: The rotation period will be _______________ to _______________.

2. UConn SOM Liaison: Dr. ______________________________ will be providing supervision for(first and last name)

the resident/fellow named above.

3. Additional UConn SOM Liaison: If the resident/fellow will be assigned to an affiliated hospital site,the Assistant Dean for Education at that site and/or the rotation supervisor at that site will beconsulted by the UConn SOM Liaison for additional approval and sign-off.

4. Sponsoring Institution Liaison:___________________________________ will serve as the(resident / fellow’s program director/GME DIO)

sponsoring Institution’s liaison with the UConn SOM.

5. Title of Rotation:______________________________________________Resident/Fellow will participate in this rotation and will be expected to meet the goals andobjectives. The specific description of this rotation with goals, objectives, and evaluationmodalities is attached to the document.

6. Resident/Fellow’s Responsibilities:a. Comply with all policies, procedures, rules and regulations of UConn SOM and affiliated sites.b. Assume responsibility for his/her own uniforms, transportation, housing, meals, and other

personal needs in the performance of activities under this rotation when such things are notprovided by UConn SOM.

c. Maintain the confidentiality of all information in UConn SOM records, including but not limitedto patient records, research designed, and protocols. Resident/Fellow is prohibited fromdisclosing confidential material and/or publishing any writings that relate to theresident/fellow’s experience at UConn SOM without prior written approval from UConn SOM.


d. As a condition of participation in the rotation, UConn SOM’s Employee Student Health mustreview the resident/fellow’s immunization records to ensure they comply with UConn SOM’srequirements. Resident/fellow must provide such immunization records prior to the start ofthe rotation, including but not limited to one of the following;1. Certification of compliance with the resident/fellow’s sponsoring institution’s requisite

employee health screening policy if such policy includes regular tuberculosis screening; or2. Proof of a history of vaccinations sufficient to meet UConn SOM’s Employee Student

Health’s guidelines (CDC recommendations) including proof of a negative tuberculosisscreening test within the thirty (30) day period immediately prior to the beginning of therotation. Rotations occurring between October 1 and March 31st require theresident/fellow to present having received a flu shot prior to the start of the rotation.

All (if any) outstanding vaccinations as determined by UConn SOM’s Employee Student Health must be obtained at the Sponsoring Institution prior to starting the UConn SOM rotation. Proof of such must be must be submit along with the Letter in order to receive final clearance to begin the rotation.

e. As a condition of participation in the rotation, the resident fellow must clear a backgroundcheck. UConn Public Safety will perform a background check at a cost of $75. If you had abackground check performed within the twelve (12) months from the start of the rotation,please provide a copy. UConn Public Safety will review the documentation and make the finaldetermination if it is acceptable or if an additional background check is needed.

UConn SOM reserves the right to refuse enrollment with regard to, and/or dismiss any candidate or resident/fellow that does not meet the criteria in Section 6.

7. Sponsoring Institution’s Responsibilitiesa. Confer academic credit, if applicable to resident/fellow, upon successfully attaining goals set

for this rotation.b. Ensure the resident/fellow complies with the provisions of Section 6 of this letter.c. Maintain professional liability insurance coverage or proof of self-insurance for resident/fellow

while participating in the rotation in the minimum amount of one million/three million($1,000,000/$3,000,000) and will provide current proof of such insurance. Failure to obtain ormaintain such coverage will, at UConn SOM’s option, be cause for termination of this rotationand immediate removal of the resident/fellow from UConn SOM.

d. If applicable, ensure the resident /fellow has secured and maintains all documentation requiredfor the resident/fellow to enter and stay in the United States and to allow the resident/fellowto participate in the rotation.

e. Ensure the resident/fellow has satisfactorily completed any courses and/or trainings that areprerequisites for participation in the rotation.

f. Ensure the resident/fellow is in good standing in their program without any limitations orunder a remedial program and has achieved ACGME core competencies at the expected levelfor this time in the program.

g. Ensure the resident/fellow has cleared a background check done by the Sponsoring Institutionor designee. If a background check has not been completed within twelve (12) months fromthe start of the rotation, the UConn SOM will perform one for a fee (see section 6e).

h. Provide resident/fellow with full salary and continued benefits, including personal healthinsurance during the period of this rotation.

i. Provide UConn SOM with a photo of the resident/fellow with attestation the photo is theresident/fellow in question.

j. Provide a list of procedures specific to this rotation that this resident/fellow is credentialed toperform at the sponsoring institution. Note: UConn SOM reserves the right to re-credentialvisiting residents/fellows for all procedures.


8. UConn SOM’s Rights and Responsibilities:a. Provide input to the Sponsoring Institution’s Liaison regarding the resident/fellow’s

performance for evaluation purposes;b. Provide an orientation period for resident/fellow to inform them of UConn SOM facilities,

policies, procedures, rules and regulations;c. Arrange for emergency health care for resident/fellow if needed while they are onsite at

UConn SOM, or assigned site. However, UConn SOM will not be responsible for costs, followup care, or hospitalization associated with such emergency care; and

d. Have the right, in its sole discretion, to immediately dismiss resident/fellow from UConn SOMthereby terminating the rotation, if UConn SOM determines that;1. The presence of the resident/fellow has a detrimental effect upon UConn SOM’s facilities,

patients, or personnel;2. Resident/fellow is compromising UConn SOM’s standard of care or performance, policies

or procedures; and/or3. The proper liability insurance coverage is not in effect.

e. Once the resident/fellow has been fully approved to participate in a UConn SOM sponsoredprogram, the program coordinator will obtain access to the appropriate patient recordsystem(s).

f. Claim the appropriate percentage of time spent training in a UConn sponsored program inaccordance with Medicare regulations (on Medicare IRIS).

9. The resident/fellow participating in this rotation will not be an employee of UConn SOM/ CapitalArea Health Consortium (CAHC) and will have no claim against UConn SOM/ CAHC for anyemployment benefits. At no time will the resident /fellow or sponsoring institution’s personnel beconsidered or represent themselves as agents, either express or apparent, officers, servants, oremployees of UConn SOM. Sponsoring Institution’s resident/fellow will wear nametags at all timesidentifying his/her status.

10. Indemnification: To the extent authorized under the Constitution and laws of the home state ofthe Sponsoring Institution will indemnify and hold UConn SOM, its officers, agents and employeesharmless against any and all claims, demands, damages, liabilities, and costs which directly orindirectly result from, or arise in connection with any willful misconduct or any negligent act oromission of the Sponsoring Institution, its officers, agents, employees, or resident/fellow pertainingto its activities and obligations under this Letter.

11. Except as otherwise required by law or regulation, Sponsoring Institution will not use, release, ordistribute any materials or information containing the name or logo of UConn SOM or any of itsemployees without the prior written approval of an authorized representative of UConn SOM.

12. UConn SOM and the Sponsoring Institution shall comply with all Federal, State, and Local statutesand regulations including those prohibiting discrimination on the basis of race, color, creed, sex,age, marital status, handicap, national origin, sexual preference or any other basis prohibited bylaw. In addition to the foregoing, each of the parties agrees to comply with all the requirements ofpertinent accrediting agencies. In the event of non-compliance, this Agreement may be terminatedimmediately.

13. By signing this Letter, the representative of the Sponsoring Institution thereby represents that suchperson is duly authorized by the Sponsoring Institution to execute this letter on behalf of theSponsoring Institution and agrees to be bound by the provisions thereof.


14. This Letter sets forth the entire understanding between the parties with respect to the subjectmatter hereof.

If there is agreement with the above conditions regarding the commitment made on behalf of the Sponsoring Institution and the resident/fellow under this Letter, please have a duly authorized representative of the Sponsoring Institution sign duplicate originals in the designated spaces and return both originals for further processing to the Liaison and Department in #2 at: UConn School of Medicine, 263 Farmington Avenue, Farmington, CT 06030.

Approved and Accepted:

____________________________________ (Signature)

By: _________________________________ (print name) Sponsoring Institution DIO or Designee

Date: _______________________________

Sponsoring Institution Read and Understood

____________________________________ (Signature) By: Resident/ Fellow’s Program Director

Date: _______________________________

____________________________________ (Signature)

By: Jillian Goldsmith Graduate Medical Education, UConn SOM

Date: _______________________________

UConn SOM Read and Understood

____________________________________ (Signature) By: Liaison/ Program Director

Date: _______________________________

If needed:

__________________________________________________________________________________ Site director assigned site- signature, printed name, and date

__________________________________________________________________________________ Assistant Dean for Medical Education- assigned site- printed name, date, and signature


Connecticut Children’s Medical Center 282 Washington Street

Hartford, Ct 06106

De-Identifying PHI Agreement

I hereby acknowledge that I have received and read Connecticut Children’s policies and procedures on the use and disclosure of De-identified and Re-identified protected health information located on pages 13 and 14 of the Guide to CT Children’s Medical Center Brochure.

I understand the Connecticut Children’s policies and procedures relating to the privacy of protected health information. I understand that if I violate a patient’s rights to privacy and confidentiality, I may be subject to civil or criminal legal action.

I hereby agree to abide by and comply with Connecticut Children’s policies and procedures relating to the use and disclosure of de-identified and re-identified protected health information.

Name/Signature Date

"If completing this form electronically, typing your name in the signature space provided above will be considered a legally binding signature indicating your approval of and agreement to the terms/conditions contained in this document."

Revised: 5/10/16

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CONNECTICUT CHILDREN’S MEDICAL CENTER & AFFILIATES AND SUBSIDIARIES OF CCMC CORPORATION

CONFIDENTIALITY AGREEMENT

I, understand that in the course of my work and/or visit as an (Print Full Name)

employee, contracted/temporary staff member, student volunteer vendor, or other (specify): At Connecticut Children’s

Medical Center, including all affiliates and subsidiaries of CCMC Corporation, hereinafter referred to as ”Connecticut Children’s,” I may have access to Confidential Information, including patient health information, sensitive personal information, or other sensitive business information.

Confidential Information means any information obtained as a result of my affiliation with Connecticut Children’s that is not generally known or accessible to the public, whether or not expressly identified to me as confidential, including but not limited to information that falls into one or more of the following categories: 1. Any records or information, whether financial, medical or personal, regarding the identity,

history, condition, care, treatment or billing of a Connecticut Children’s patient (also knownas Protected Health Information or PHI).

2. Any records or information relating to Connecticut Children’s medical staff credentialing,discipline or other peer review activities.

3. Any records or information pertaining to Connecticut Children’s or its business partners’operations; strategic, marketing or business plans; acquisitions, costs, financials, orcontracts; or other business information that is not generally known to the public.

4. Any records or information related to a pending, threatened or potential lawsuit oradministrative, civil, criminal or other legal claim by or against Connecticut Children’s.

5. Any records or information concerning Connecticut Children’s employees, including but notlimited to health records and personnel records.

By signing this document, I agree: 1. To abide by all of Connecticut Children’s policies, procedures, and guidelines relating to the

use, access, and protection of Confidential Information.2. To hold in strictest confidence and maintain the privacy of all Confidential Information and

not to disclose Confidential Information except as permitted by the organization’s policies,procedures and guidelines. I must protect the privacy of all Confidential Information at alltimes, including discussions with family or friends when I am off duty or am no longerassociated with Connecticut Children’s.

3. That I have no right or ownership interest in Confidential Information.4. To immediately report to the organization any use or disclosure of Confidential Information

that is not permitted by this Agreement and to take any action necessary or requested bythe organization to mitigate, to the extent practicable, any harmful effect that is known tome of a use or disclosure of Confidential Information in violation of applicable law or theorganization’s policies, procedures or guidelines.

Visiting ResidentX

5. That I will access Confidential Information for the sole purpose of performing my approvedposition responsibilities and will not access Confidential Information at the request of otherswho do not have a need or right to access to such Confidential Information.

6. To appropriately use Confidential Information only in connection with the performance ofmy approved position responsibilities; to use only the minimum necessary patient healthinformation required to perform my assigned function or job; and not remove ConfidentialInformation from Connecticut Children’s premises, except as required by my position and inaccordance with the organization’s policies, procedures and guidelines.

7. That I will not discuss Confidential Information where unauthorized persons can overhearthe conversation; and will not leave Confidential Information where it can be seen byunauthorized persons.

8. That I will not leave my computer terminal unattended or unsecured while on-line or shareor lend my user password or authentication code with any other person.

9. To ensure that all Confidential Information is retained and destroyed in accordance with theorganization’s policy, procedures and guidelines.

By signing this document, I understand that: 1. The access to and use of Confidential Information is subject to regular audit and

monitoring.2. The restrictions described in this Agreement are in force at all times and in all locations of

the organization.3. If I fail to comply with the terms of this Agreement or Connecticut Children’s confidentiality

policies, I may be subject to disciplinary action, up to and including termination from myposition (or, in the case of a vendor, becoming banned from Connecticut Children’spremises).

4. A patient’s right to the confidentiality of Protected Health Information is protected by statestatutes and federal laws, and by Connecticut Children’s policies, procedures andguidelines.

5. If I violate this Agreement, I may, as an individual, be subject to civil or criminal legal actionfor which I will not be provided defense counsel or insurance coverage by ConnecticutChildren’s.

My obligations under this Agreement shall survive termination of my affiliation with Connecticut Children’s and termination of this Agreement.

Signature Department

"If completing this form electronically, typing your name in the signature space provided above will be considered a legally binding signature indicating your approval of and agreement to the terms/conditions contained in this document."

Connecticut Children’s Medical Center Resident Orientation - June 2007

______________________________________________________________ Welcome to Connecticut Children’s Medical Center (CCMC)! All rotating residents and subspecialty residents are asked to read and understand this orientation module prior to your rotation at CCMC. As you read this packet, please answer the following post test questions and submit with the signed acknowledgement form located on the last page.

CCMC Compliance Education Self Learning Packet Post Test

Name: (please print):

Department Rotating: Date:

1. What are the names of the two patient representatives?

2. What should be done with paper records containing patient information when no longerneeded?

3. What is the number for security?

4. What button should be pressed if a patient, visitor or employee has cardiac or respiratoryarrest?

5. Where can a full copy of the CCMC Code of Conduct be viewed?

6. Are the following abbreviations: (IU, U, QD, QID, QOD, MSO4, MgSO4, MS, u, D)permitted?

7. What process is required prior to all non-emergent procedures, invasive or not?

Please submit this post test with the acknowledgement form located on the last page of this packet.


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1. GENERAL GUIDELINES FOR RESIDENTS• A Resident must comply with the hospital dress code and CCMC I.D. badges must be

visible at all times. Failure to wear CCMC Identification may lead you to be questionedby security and/or be asked to leave the Hospital premises.

• Body piercing(s) should be in good taste. Please refer to Human resources policy titled“Workplace Attire.”

• CCMC policies and procedures are available on the Intranet. The Internet can beaccessed by clicking on the “e” icon (Internet Explorer), which will automatically openthe CCMC home page. Using the menu on the left side of the page, scroll down to“Policies” and click. A variety of “rooms” will appear which can they be selected (e.g.,CCMC Organizational, Clinical Care, Infection Control, etc.)

• Documentation: accurate, legible, timely and complete documentation is mandated byHospital Policy & Procedures in accordance with accreditation standards and relatedlaws; please review the CCMC “do not use abbreviation” list and medication orderrequirements contained in this packet.

• A Resident must report any incident/accident to the Program Director or supervisingattending.

• At the end of your rotation, please stop by the Medical Education Office to determinewhen to return your badge

2. CUSTOMER SERVICE• n keeping with CCMC’s mission, vision, and values, the needs of customers are placed

above all. “Service excellence” standards are set to address how we interact with eachother and our customers. The Service Excellence Behavior Standards include:

• Be on stage – dress professionally and appropriately. Wear your ID badge at eye level.Greet patients and others with a positive attitude.

• Communicate with courtesy, compassion, and honesty – use clear, appropriateterminology when discussing patient care or providing information to patients andfamilies. Assists others in obtaining information and provide timely feedback.

• Telephone etiquette – answer phone promptly. Identify your department, yourself, andask “how may I help you?”

• Respect the dignity and confidence of others – assure each individual’s right to privacyand confidentiality. Respect the different customs and beliefs of patients and staff.

• Be a team player – work collaboratively with staff. Show appreciation for the effortsothers bring to team projects.


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• Act like an owner – take pride in your function and CCMC. Help keep your work areasand the hospital safe and clean.

• Be positive about your job and the organization – refrain from personal conversationsand gossip in front of others. Reinforce good behavior and acknowledge others whenyou see them go the extra mile for others.

• Anticipate the needs and concerns of our customers.

3. INFORMATION MANAGEMENT

Information Management is the process of obtaining, managing and using information to improve patient outcomes and Hospital-wide performance. Access to information is based on a need-to-know basis in order to safeguard the confidentiality of the data at all times. If you are given an Userid and password and/or security code, keep it confidential and do not share with others and sign off the computer when leaving your area. A confidentiality statement must be signed when requesting a security userid and code/password for any Hospital system.

CCMC utilizes several electronic information management systems. These include, but are not limited to: • PACS – online imaging studies• PICIS – online Emergency Department medical record and online OR (intraoperative)

medical record• CPOE – online computerized prescriber order entry system• Groupwise – email communication system

4. PATIENT BILL OF RIGHTS

CCMC has a responsibility to give every patient appropriate medical care. The Patient Bill of Rights is a set of guiding principles of patient care. The Bill of Rights is displayed in multiple public areas and in every department and is provided to educate patients about their rights as a patient at CCMC. The Patient Representative is responsible for pursuing any questions, concerns, or formal complaints patients/families may have about their rights or the quality of care and service provided by CCMC. You or your patients may contact the Patient Representative (Dahivsa Mercado and Sharyn Lopez) directly at 837-5283, pager: 220-1643.


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5. PATIENT CONFIDENTIALITY Patient confidentiality is a conscious effort by every healthcare worker to keep private all personal information revealed by patients and their families and/or medical records during a hospital visit. You may have access to confidential information about patients and their families. You must never discuss, disclose or review any information about a patient’s medical condition with any other person unless they have proper authorization. Patients and their families are entitled to privacy and it is your ethical and professional obligation to respect that privacy at all times. All are responsible for patient confidentiality. General Guidelines

• Medical record information can only be released with a proper consent signed by the parent or legal guardian, or in accordance with state or federal law.

• Refrain from having verbal conversations regarding patient information in hallways, elevators and other public places.

• Any questions regarding release of information should be directed to the HIM department

• All patient medical information must be discarded in 1) an approved confidential disposal bin, or 2) an approved shredder, as provided by the Hospital to prevent the information from being disclosed to unauthorized individuals.

General notes about HIPAA (Health Insurance Portability and Accountability Act):

• Confidentiality and privacy mean that patients have the right to control who will see their protected health information (PHI). PHI includes, but is not limited to: name, relative’s name, address, social security number, account numbers, date of birth, telephone number, fax numbers, voice or finger prints, photos, and other personal identifying information.

• Communication about patient health information should be limited to those who need the information in order to provide treatment, payment, and healthcare operations (TPO).

• When faxing patient information, double check the number. If necessary, call to ensure the fax was delivered to the correct person. Do not fax sensitive, highly protected health information (e.g., information about a patient’s drug or alcohol dependency, psychotherapy notes, HIV status, sexual assault)

• Patient privacy can be violated when PHI and patient names are left on voicemail messages or telephone answering machines.

• Computer printouts, and other paper records containing patient information, must be kept in a secure place and shredded when no longer needed.


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• You must never discuss, disclose or review any information about a patient’s medical condition with any other person unless they have proper authorization.

• HIPAA violations may include both civil and criminal penalties for the individual as well as the hospital.

Patients and their families are entitled to privacy and it is your ethical and professional obligation to respect that privacy at all times. Generally speaking, all members involved in patient care, including physicians, nurses, residents, and other staff, as well as students and volunteers are responsible for patient confidentiality. 6. ENVIRONMENT OF CARE Emergency Preparedness The hospital has established a Hospital Emergency Operations Plan (HEOP) with several “parts” as a means to prepare for and address events and emergencies. This section will help you learn how to respond to some unexpected events and emergencies. Following these procedures should help to ensure safety for you, our patients and their families. HEOP Part F = Fire If there is a fire, remember the term "RACE". RACE is a national acronym used to help you remember what you must do in case of a fire: R – Rescue/Remove Your first priority is to remove patients from immediate danger. A - Alarm Pull the fire alarm/alert Security by calling ext. 88222. C - Contain Close all doors and prepare for evacuation. E – Evacuate/Extinguish Go to the next fire zone. Evacuate horizontally following

your unit’s evacuation plan. Do not use elevators, use only stairs. Remember to Close ALL doors.

To use the fire extinguisher, remember “PASS”:

P – Pull the pin A – Aim the nozzle/hose at the base of the fire S – Squeeze the handle together S – Sweep the nozzle side to side

HEOP Part B = Bomb Threat In the event of a bomb threat, (1) contact Security at ext. 88222 immediately with the information and details; (2) cooperate fully with leaders and authorities; and (3) search your area for unfamiliar or suspicious objects (if asked or directed by leaders).


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HEOP Part A = Abduction If you find a lost child or suspect that abduction has taken place, call Security immediately at ext. 88222. Give a detailed description of the child. If a Part A is announced, immediately check your area for the child with the description provided and monitor the exits of the unit and hospital. Code Blue = Cardiac Arrest If a patient, visitor or employee has cardiac or respiratory arrest, call for help:

• Press a “Code Blue” button (a black toggle switch on a blue background with the word “CODE” inscribed above the switch. Some of the switches are covered with a clear plastic shield.) Once activated, the Code Blue button should be left in the “ON” position for several minutes. This allows the Resource Center Associate to identify the location of the alarm; or

• Dial “0” and inform the Resource Center operator that there is a “Code Blue.” The healthcare provider should inform the operator of the exact location of the medical emergency.

• Begin CPR if you are certified to do so. If you are not, wait for the team. Safety Tips You can help us make CCMC a safer place by taking steps to protect yourself:

• Report any suspicious person or unauthorized persons to Security immediately. • Do not leave your purse or wallet unattended. Keep them out of view. • Watch drug containers and packages for signs of tampering.

For children’s safety:

• Keep the following items out of reach of children: medications, needles, cleaning supplies, cords

• Latex Balloons are not allowed in the Hospital Security The Security Services department full time, professionally trained security officers. Officers are on duty 24 hours a day, 7 days a week, every day of the year. They patrol inside and outside the Hospital. In case of an emergency, call ext. 88222. Workplace Violence CCMC maintains a zero tolerance policy towards workplace violence. Any person making threats, exhibiting threatening behavior, or who engages in violent acts on the property of the hospital will be removed from the premises by Security. If you witness or are involved in a potential violent situation, call Security at ext. 88222.


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Patient Care (Standard) Precautions: Standard Precautions are a set of standardized precautions to be used for all patients, regardless of illness or medical condition. These procedures were originally designed to manage possible exposures to blood borne viruses such as HIV or Hepatitis B, but have evolved to include procedures that will reduce exposures to other pathogens as well. These precautions incorporate hand washing, personal protective equipment, sharps safety and cleaning and disinfection. The second tier is contact, droplet and airborne precautions. Signs are posted on patient doors to inform staff and visitors to take applicable precautions. Infection Control To contact the office, call ext. 5-9392 Jennifer Martin, Nurse Epidemiologist. CCMC has a comprehensive infection control plan with policies and procedures designed to prevent and control infection in patients, families, visitors, employees and others who may use our service or work on site. Policies of particular concern are available on the CCMC intranet.

General Infection Control Guidelines All residents need to follow a basic level of caution during their work activities. These include: • Clean uniforms/clothing; long hair should be restrained or tied back. • Avoid touching eyes or mouth during patient contact activities. • No eating or drinking in areas where patient contact activities • Routine handwashing whenever contamination might have occurred and in-between all

patient contact.


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7. CORPORATE COMPLIANCE EMTALA stands for the Emergency Medical Treatment Active Labor Act. You may also hear it referred to as COBRA or the Anti-Patient Dumping Statute.

Important Things to Remember EMTALA prohibits hospital EDs from delaying care, refusing treatment, or transferring patients to another hospital based on their inability to pay for services. Hospitals and physicians cannot delay medical screening (examination) or treatment to inquire about the patient's method of payment or insurance status. Anyone (child or adult) on the Hospital grounds/property, who needs to be examined or who requests a medical examination, receive a medical screening by a doctor. We do not refuse anyone who needs or requests medical treatment. Your Role Is Very Important : If anyone comes up to you and asks you or tells you that they want to be seen by a doctor, or needs to be seen for medical care, take them to the Emergency room right away.

Corporate Compliance Healthcare corporate compliance refers to an organization’s ability to operate within the rules, regulations, and policies created by the facility, government, regulatory agencies or payers. For CCMC, this means “doing it right even when no one is looking.” CCMC is committed to the delivery of high quality health care through the ability and professionalism of the CCMC staff. Everyone has a hand in compliance and can help ensure that CCMC maintains the highest standards of legal and ethical excellence by asking questions and/or informing your supervisor of any suspected compliance violations. Code of Conduct The CCMC/FPP Code of Conduct defines our expectations for behavior in the work environment. The Code of Conduct, which incorporates eight standards as described in this document, provide specific guidance applicable to all “Staff”, defined as the Board of Directors, employees, members of the medical staff, allied health professionals, students, residents, volunteers, contractors, and agents. (Please refer to the CCMC intranet for a full copy of the Code of Conduct.) Standard 1 Legal Compliance – All Staff must comply with federal and state laws. These laws include but are not limited to: discrimination, fraud and abuse, environmental safety, antitrust, political activities, taxation, billing and coding, and recordkeeping (access and retention).


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Standard 2 Business Ethics – All Staff must accurately and honestly represent CCMC/FPP and must not engage in any activity to scheme or defraud anyone or the organization of money, property or services. Such ethical behavior includes, but is not limited to protection of human subjects in research, scientific integrity, receipt of donations, and professional organization standards. Standard 3 Confidentiality – All Staff must maintain the confidentiality of patient, employee and other proprietary information according to legal and ethical standards. Standard 4 Conflict of Interest – All Staff must not use his/her position to profit personally or to assist others in profiting in any way at the expense of the organization. All Staff must disclose any actual or potential conflicts to the Compliance Office, as well as remove themselves from situations where there is or may be the possibility of a conflict of interest. Standard 5 Business Relationships – All business transactions with all third parties must be completely ethical and legal. Staff must not offer, give, solicit, or receive any form of bribe or other improper payment or inducement. All marketing activities must be honest, straightforward, fully informative and non-deceptive. Standard 6 Protection of Assets – All Staff must protect the assets of the organization through efficient and effective use of resources. Organization assets must be maintained solely for business related purposes and must not be used for private or personal interest. Standard 7 Quality of Care – All Staff must commit to providing high quality and safe patient care as defined by our mission and vision and must respect the rights of patients and families. Staff have a duty to report any patient-related deficiency, error or variance, regardless of magnitude or significance. Standard 8 Administration – The Compliance Officer shall work with others with respect to the implementation and enforcement of the Code of Conduct. Staff must report suspected or actual violations. 8. Patient Safety Red Rule – A Red Rule is a rule that is always invoked to prevent errors from occurring. CCMC’s Red Rule is to always use two patient identifiers for every patient encounter. The identifiers may include patient name and medical record number or date of birth. SBAR – SBAR is a technique which provides a framework for effective communication among the healthcare team. When conducting a patient hand-off, use the SBAR technique:

S – Situation (concise statement of the problem) B – Background (pertinent and brief information related to situation) A – Assessment (analysis and considerations of options – what you found/think) R – Recommendation (action requested/recommended – what you want)


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Do not use abbreviations – List of abbreviations deemed unacceptable for use in any portion of the patient’s record. These include:

Do Not Use Preferred Term U Units IU International Units QD Daily QID Four times daily QOD Every other day MSO4 Morphine sulfate MgSO4 Magnesium sulfate MS Morphine sulfate or Magnesium sulfate µ Microgram D Dose D Day Do not use a trailing zero or fail to use a leading zero

Use 5 or 0.5

Bed Sharing CCMC prohibits parent/legal guardian bed sharing with child less than six months of age. Child Protection and Abuse All CCMC staff have a duty to recognize and respond to cases of suspected child abuse or neglect. State law mandates that the health care providers with direct contact with children report all cases of abuse and neglect to the Connecticut Department of Children’s and Families (DCF). CCMC has a Child Protection Team that serves as a consulting body to all staff and offers guidance with the reporting process as needed. The Team can be reached by calling ext. 5-9700.


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Universal Protocol (Time Out for Safety) CCMC policy requires a "time out" be performed prior to all non-emergent procedures (invasive or not) where the patient will receive more than minimal sedation, as well as, all invasive procedures. The final time out is the last step of the pre-procedure verification process, which involves the ongoing gathering and verification of information, starting with the decision to do the procedure, and ending with the "time out" right before the start of the procedure. The time out should occur before the patient receives conscious sedation for the procedure. The “time out” includes verification of:

• correct patient, • correct side and site, • correct procedure, • correct patient position, • availability of correct implants and any special equipment or special requirements, • correct operator, and • correct informed consent.

Chain of Command CCMC policy requires staff to use the chain of command if they have concerns about a patient or the quality of care being delivered to a patient. The CCMC chain of command includes the following steps:

1. Call or page the junior resident or APRN. 2. If the response is insufficient or in question, page the senior resident. 3. In the NICU, if the response is insufficient or in question, page the Fellow. 4. If the response is insufficient or in question, call the resource registered nurse. 5. If the response is insufficient or in question, call or page the attending physician. 6. If these avenues fail to achieve a satisfactory result, page the Medical Director of

the unit where the patient is located. • Medical Surgical Units – Medical Director

Beeper 220-2892 • Pediatric Intensive Care Unit – Medical Director

Beeper 220-2106 • Neonatal Intensive Care Unit – Medical Director

Beeper 220-2033 • Emergency Department – Medical Director

Beeper 220-1726 • OR/PACU – Medical Director

Beeper 842-4745

9. Important Numbers Corporate Compliance: Kathie Arbuckle – CCMC Corporate Compliance Officer (860) 545–8123; Dean Rapoza – FPP Corporate Compliance Officer (860) 545-9338 or Deborah Weber– FPP Corporate Compliance Coordinator (860) 545-9271 Risk Management: Patricia GaNun 545-9016


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ACKNOWLEDGEMENT I, have read and understand the orientation for

Rotating Residents at Connecticut Children’s Medical Center and I will abide

by the principles outlined in the document.

Signature Date "If completing this form electronically, typing your name in the signature space provided above will be considered a legally binding signature indicating your approval of and agreement to the terms/conditions contained in this document."

Reviewed: 4/1/11

Connecticut Children’s Medical Center

HIPAA Education

Health Insurance Portability and Accountability Act

Employee Self-learning Program

March 2003

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What is HIPAA? HIPAA stands for Health Insurance Portability and Accountability Act. This Act was signed into law in 1996 with regulations effective April 14, 2003. The 3 key focus areas of this law are to: Keep healthcare data secure Keep personal health information private Standardize the formats for electronic billing in healthcare

HIPAA is designed to maintain the privacy of protected health information. This applies not only to patient charts and medical records, but to registration, billing and other financial information as well. It includes all written, oral, and electronic information. What is Protected Health Information (PHI)? Protected Health Information is any medical record information that is created, received, or maintained regarding the treatment of a patient. This includes all past, present, or future physical or mental health care provided to an individual and information about the payment of such care that identifies the person in any way. There are penalties including fines and jail time if an individual or organization is found to have misused patient information. If you discover a staff member not using PHI correctly, you should inform your manager or the Privacy Officer. How does HIPAA affect CCMC? CCMC is required to develop appropriate procedures, processes, and training to meet the HIPAA requirements. See the Intranet for details. Some of these requirements include: Having a Privacy Officer. Liz Tetreault from the Health Information Department is

CCMC’s Privacy Officer. Providing a Privacy Notice to all patients/family. Assuring all parties that their concerns about privacy will be treated without retribution.

Who can I share information with on behalf of the patient? No matter what your role (employee, student, volunteer, vendor) is at the Medical Center, you come across information about patients in some way. Never request nor disclose a patient’s personal information to anyone who does not have a specific, job-related, “need to know”. Patient information can be shared with any party that is involved in the direct treatment of that patient. Both the person disclosing the information and the person requesting the information must have a job-related, “need to know.” Patient information can be shared with any party that is involved in the payment of the services related to the patient’s care. Again, all parties must have a job-related need to know the information. Patient information can be shared with internal CCMC staff that need to have access to personal patient information do their job. Patient information can be shared with companies that CCMC uses to support the Treatment, Payment, and/or Operations (TPO) of patient care. These companies must have HIPAA

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confidentiality agreements called Business Associate Agreements in place with CCMC. Contact the Privacy Officer for any questions about a specific company’s agreement. Examples are: Transcription Companies Press Ganey Patient Satisfaction Survey Company JCAHO/DPH Hartford Hospital

Who must have a patient written authorization to receive patient Information? A written authorization from the patient/family is required in order for CCMC to release patient information to any external party that does not require CCMC for public reporting of patient information. Examples are: Attorney offices Social Security benefit office Police departments

How does HIPAA affect the patient? The patient/family will receive a Notice of Privacy each time they are treated at CCMC. A Notice of Privacy is a written document that describes how the Medical Center uses/discloses and protects the patient’s information. (See the Intranet – HIPAA Reference Site for a sample.) Patients and families will need to acknowledge that they received the information as soon as possible. Patients cannot be denied treatment if they refuse to acknowledge receipt. The patient/family has the right to request restrictions on the use of their information. These restrictions apply to: Patient status information available to the public via the public directory Patient request for confidential communication Others restriction requests will be reviewed by the CCMC Privacy Officer

The patient/family can request a list of all disclosures of patient information that were not used for treatment, payment or internal CCMC operations. Examples of this would include:

Research Legal requests State/Federal reporting

When information is disclosed, it is generally limited to the minimum amount of information that is needed for the purpose of the requested release. This is referred to as “minimum necessary” disclosure. Please see the HIPAA Room on the Intranet for detail listing of the items that require a patient authorization. All such disclosers must be documented in the patient’s medical record. The patient/family has the right to request corrections to the information stored in their medical record. How does HIPAA affect marketing or fundraising? All marketing by external parties is prohibited.

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Fundraising is accepted, but it cannot be diagnosis specific. All fundraising activities must be approved and coordinated through the Foundation. How do the HIPAA regulations affect me? All employees are responsible for keeping patient information private and secure. If there is any chance information may be confidential, it must be treated as such. Each person is responsible to do the following as related to their job: Keep all verbal communication appropriate. Never discuss patient information outside of work. Be careful not to discuss patient information in hallways, elevators, cafeteria, or common

areas where others might overhear you. Speak in a normal tone of voice to the appropriate people when discussing patient

information. Use judgment to share only the information that is needed, do not give extra details.

Keep all written documentation secure. Never leave medical files unattended on desks, in patient rooms, and other public places

or areas with unauthorized personnel. Make sure patient files are closed and stored in the designated spot. Never remove patient information from the Medical Center. Properly dispose of documents in a confidential waste container.

Keep all computer information secure. Never share a computer password or security code. Make sure computer screens cannot be viewed by the public. Remember to close screens with patient information when walking away from the

computer. Remove printouts of patient information from the printer promptly. Dispose of extra and

imperfect copies in the confidential waste container. Never send external email with patient information unless you have written authorization

from the patient/family. Keep fax machine use safe and secure. Remove all faxes from the machine as soon as possible. Confirm fax numbers before sending patient information. Use a cover sheet stating that the information being sent is confidential. Verify that the transmission was received.

Keep telephone conversations safe and secure. Health information should only be shared with the patient, parent, or legal guardian. Do not leave confidential information on answering machines/voice mail. Limit

information to the name of the caller, CCMC or department, and a contact number. Verify the caller by asking whom you are speaking to.

Internal Review Board (IRB) approval is required before any research can be performed. Never share patient information collected in any database without an authorization from the patient/family.

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Resources Refer the to CCMC Intranet, HIPAA Reference Site, for all related policies, sample documents, and other education materials. Contact the Privacy Officer, Liz Tetreault, or HIPAA Task Force members for questions and additional information. Review Questions After reviewing the HIPAA material, complete the following review questions. Use the separate answer sheet to record your answers. Return the completed answer sheet to your manager. Your manager will have the questions corrected and will review them with you. 1. If patient health information is misused which of the following could result?

a. CCMC could be fined b. The staff involved could be fined c. The staff involved could go to jail d. All of the above

2. The Notice of Privacy: a. Describes how CCMC uses/releases patient information b. Describes how CCMC protects the patient’s information c. Is not required at a children’s hospital. d. Both A and B

3. Which safeguard is NOT required to protect health information? a. Protecting medical records from public access b. Not sharing computer passwords c. Discarding papers containing medical information in the regular trash d. Positioning computer screens away from the public

4. Patients can be denied treatment if they refuse to accept the Privacy Notice or fail to sign they received it. T or F 5. When is a patient’s written authorization for disclosing patient information required?

a. When admitted b. For external parties not involved in the treatment or payment of the patient’s care c. When billing the insurance company d. None of the above

6. When faxing patient information, which of the following is required: a. Using a cover sheet stating information is confidential b. Faxing the information and verifying it was received c. Verifying the number before faxing d. All of the above

7. I can share information with any treatment provider that does not have a current, direct relationship with the patient. T or F

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8. Protected Health Information only covers the patient’s diagnosis not their address or phone number. T or F 9. You discover that a neighbor’s child is being treated at the Medical Center. You are not directly involved in the child’s care. What should you do?

a. Do nothing b. Call your neighbor c. Tell the unit staff that you know how to reach the child’s family, if needed d. Call other neighbors to remind them to visit the child

10. Before doing research which requires collecting data from medical records, I should: a. Begin reviewing medical charts immediately before they are archived b. Contact the Health Information Department c. Obtain prior approval from the Research Department d. There a no restrictions when doing chart reviews for research

11. Protected health information can be found in which form? a. Paper b. Electronic c. Verbal d. All of the above

12. It is okay to discuss patient information in public areas as long the patient’s name is not used. T or F Reviewed: 4/1/11

Connecticut Children’s Medical Center

HIPAA Training Test Name: Rotation Name: Rotation Dates: Rotation Supervisor: Date Test Completed: Directions: After reading the HIPAA training materials please the review questions at the end of the packet and record your answers to the questions on this answer sheet. For each question, check off the correct answer. When done return this answer sheet to the ccmc central registrar. The registrar will have the answers corrected and will review your answers with you.

Question # Fill in ONE answer for each question.

1 A B C D

2 A B C D

3 A B C D

4 True False

5 A B C D

6 A B C D

7 True False

8 True False

9 A B C D

10 A B C D

11 A B C D

12 True False Resident: I acknowledge that I have read and understand the material presented in the HIPAA training packet. I have completed the HIPAA validation test, and will submit to the central registrar to correct. Will review incorrect answers with registrar. Name: Date: CCMC Central Registrar: I acknowledge that the HIPAA training material has been presented to the employee; the employee has completed the HIPPA validation test, and the corrected test has been reviewed with the employee. Name: Date: Revised: 2/26/14

CONNECITCUT CHILDREN’S MEDICAL CENTER ELECTRONIC MEDICAL RECORD ACCESS & ESIGNATURE ACKNOWLEDGEMENT

POLICY AND PROCEDURE

SYSTEM USER AGREEMENT The Connecticut Children’s Medical Center (CCMC) agrees to provide access to its Electronic Health Records System (EHR) (medical records system) to (Name of individual) herein referred to as “system user” of EHR on the following conditions, and in keeping with the CCMC’s policies including, “Patient Health Information Confidentiality,” and “Electronic Signature” policy and procedure. The System User includes a member of the Connecticut Children’s Medical Center Staff, a Connecticut Children’s Medical Center employed clinician, and or medical staff member. ACCESS PROCEDURE: As part of the healthcare operations of CCMC, the System User may gain access to individually identifiable health information of a patient for the purpose of providing medical care to that patient only or for health care operations. The System User will access the system by using their Novell sign-on/password. The password may not be shared with others in the office or in the department nor assigned to another person. The use of electronic signatures in medical record documentation is an approved method of documentation by Connecticut Children’s Medical Center healthcare providers. The method of applying a user name and password together allows the computer system to create the electronic signature. Before applying an electronic signature by entering their password, healthcare providers are required to review their entries for completeness and accuracy, correcting or modifying the entry as needed. All versions of a document that result from editing or addendum to a document will remain as a permanent part of the patient’s medical record. CONFIDENTIALITY/ELECTRONIC SIGNATURE ACKNOWLEDGMENT: By signing this Agreement, the System User agrees that the individually identifiable health information accessed through paper or electronic means remains the property of CCMC. Re-disclosure or release of medical information from the CCMC computer system to any other person or entity is EXPRESSLY FORBIDDEN. The system user must maintain the confidentiality of their password to assure that only the authorized individual can apply a specific electronic signature. The organization will maintain a list of physicians or other healthcare providers who are authorized to use electronic signatures. CCMC Information Systems will maintain a list of the providers’ computer user names and pass words under appropriate safeguards. The System User guarantees that at no time will s/he disclose or provide access to his/her password to any other individual or entity. Disclosure may result in immediate termination of the System User’s electronic access and other penalties. The System User agrees further that s/he will not allow others to access patient data through the System User’s password at any time.

All providers using electronic signatures must first sign a statement that s/he is the only one who has access to and will use his/her specific password. This means the user of this password cannot be delegated to another person. Misuse of computer access passwords is punishable by removable of electronic signature privilege and possibly the loss of other privileges and employment at CCMC. ACKNOWLEDGMENT OF RESPONSIBILITY: CCMC maintains the responsibility for obtaining, transcribing, and archiving electronic data for patients under its care. CCMC agrees to maintain the integrity of the internal system by performing periodic audits of random records and by providing systems upgrades and features, as reasonably made available by the software/hardware vendor The System User has ultimate responsibility for maintaining control of the personal access code, the EHR and any electronic data which he or she views, prints, or otherwise obtains through the use of the (electronic medical record). The System User understands that the disclosure of individually identifiable health information about a patient to any other person or entity is a HIPAA violation and is punishable by a fine and other penalties. ANY SYSTEM USER WHO HAS ACCESSED INFORMATION BEYOND THAT ALLOWED UNDER THIS AGREEMENT MANY PERMANTENTLY LOSE ACCESS TO ELECTRIONIC RECORDS. IN ADDITION, THE SYSTEM USER’S AGENCY OR MEDICAL OFFICE/PRACTICE WILL BE INFORMED OF THE INAPPROPRIATE ACCESS AND FURTHER ACTION MAY BE TAKEN AGAINST THE INDIVIDUAL, OR THE AGENCY FOR BREACHES OF THIS AGREEMENT. UP TO AND INCLUDING IMMEDIATE TERMINATION. System User Signature: "If completing this form electronically, typing

your name in the signature space provided above will be considered a legally binding signature indicating your approval of and agreement to the terms/conditions contained in this document."

Required For Physician Practice Staff Only Authorizing Medical Staff Signature: Date: Printed Name of Authorizing Medical Staff: Revised: 4/15/14

UntitledCCMC.pdfUNIVERSITY OF CONNECTICUT and OTHER AFFILIATED PROGRAMSRESIDENT/FELLOW REGISTRATION and ASSIGNMENT AUTHORIZATION FORM

item 4.pdfSelf Learning Packet Post Test1. GENERAL GUIDELINES FOR RESIDENTS2. CUSTOMER SERVICE3. INFORMATION MANAGEMENT4. PATIENT BILL OF RIGHTSCCMC has a responsibility to give every patient appropriate medical care. The Patient Bill of Rights is a set of guiding principles of patient care. The Bill of Rights is displayed in multiple public areas and in every department and is provided to ...5. PATIENT CONFIDENTIALITYPatient confidentiality is a conscious effort by every healthcare worker to keep private all personal information revealed by patients and their families and/or medical records during a hospital visit. You may have access to confidential information a...

Emergency Preparedness

item 5-HIPAA.pdfEmployee Self-learning ProgramMarch 2003What is HIPAA?Resources

item 6- HIPAA answer.pdfConnecticut Children’s Medical CenterHIPAA Training Test

Name: Rotation Name: Rotation Supervisor: Rotation Dates: Date Test Completed:

item 7- systems.pdfELECTRONIC MEDICAL RECORD ACCESS & ESIGNATURE ACKNOWLEDGEMENT POLICY AND PROCEDURESYSTEM USER AGREEMENTRequired For Physician Practice Staff Only

Medical School: Grad Date: ECFMG Date if applicable: Sponsoring Institution Liaison: Date: Date_2: print name: Date_3: Date_4: M/F: Y/N: What training program are you planning on entering: Y / N: Name: UConn Program Director Name: Sponsoring Institution: UConn Program Requested: Start Date: End Date: Name of Rotation: Degree: Pager #: Street Address: City: State: Zip: Email: DOB: Group10: OffDEA #: NPI: Epic Training Site: Type of EPIC Training: Current Residency Training Program: Res Start Date: Res End Date: Group11: OffPGY: Current Residency Training Program Director: PD Phone #: PD Email: PC Name: PC Phone #: PC Email: Rotation Supervisor: Rotation Supervisor 2: Start: End: Group12: OffContact Phone: Group13: OffVisa Status if applicable: SSN: UConn SOM Liaison: Group2: OffGroup3: OffGroup4: OffGroup5: OffGroup6: OffGroup7: OffGroup8: OffGroup9: OffText3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: Text23: Text24: Date3_af_date: Date5_af_date:

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